Cases & Commentaries
Approach to Improving SafetySafety TargetResource TypeSetting of CareError Types
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with fever and hypotension. After assessment by the emergency physician, administration of intravenous crystalloid and empiric broad-spectrum antibiotics, the patient was assessed by his oncologist. Based on the patient's several recent admissions and the results of a blood culture drawn during the last admission, the oncologist added an order for Diflucan (fluconazole) 100 mg IV to cover a possible fungal infection.
Because intravenous fluconazole was not kept in the ED, the nurse phoned the pharmacy to send the medication as soon as possible. A 50 ml bottle of Diprivan (propofol, an intravenous sedative-hypnotic commonly used in anesthesia) that had been mistakenly labeled in the pharmacy as "Diflucan 100 mg/50 mL" was sent to the emergency department. Because the nurse also worked in the medical intensive care unit, she was quite familiar with both intravenous Diflucan and Diprivan. When a glass bottle containing an opaque liquid arrived instead of the plastic bag containing a clear solution that she expected, she thought that something might be amiss.
As she was about to telephone the pharmacy for clarification, a physician demanding her immediate assistance with another patient distracted her. Several minutes later, when she re-entered the room of the leukemia patient, she forgot what she had been planning to do before the interruption and simply hung the medication, connecting the bottle of Diprivan to the patient's subclavian line.
The patient's IV pump alarmed less than one minute later due to air in the line. Fortunately, in removing the air from the line, the nurse again noted the unusual appearance of the "Diflucan" and realized that she had been distracted before she could pursue the matter with the pharmacy. She stopped the infusion immediately and sent the bottle back to the pharmacy, which confirmed that Diprivan had mistakenly been dispensed in place of Diflucan.
The patient experienced no adverse effects—presumably he received none of the Diprivan, given the air in the line, the infusion time of less than a minute, and the absence of clinical effect (Diprivan is a rapidly-acting agent). Nonetheless, the ED and pharmacy flagged this as a potentially fatal medication error and pursued a joint, interdisciplinary root cause analysis, which identified the following contributing factors: (i) Nearly 600 orders of medication labels are manually prepared and sorted daily; (ii) Labels are printed in "batch" by floor instead of by drug; (iii) The medications have "look-alike" brand names; (iv) A pharmacy technician trainee was working in IV medication preparation room at the time; and (v) The nurse had been "yelled at" the day before by another physician—she attributed her immediate and total diversion of attention in large part to her fear of a similar episode.
Interruptions, Distractions, and Multitasking: Ubiquitous Threats to Patient Safety
This "near miss" is rich, complex, and subtle. It illustrates how the "messy details" of technical work—those factors investigators would usually like to ignore or eliminate—are in fact the most important objects of study, if we are to gain a deeper understanding of the genesis of success or failure in medical work.(1) Viewing this case as only an issue of mislabeling involving look-alike and sound-alike drug names misses much of its value.
Although this specific incident involves the interruption and distraction of a nurse, the general issue of interruptions and distractions relates to physicians' daily work as well. Particularly in high tempo settings, such as the emergency department, health care workers are immersed in a flood of communications, interruptions, distractions, notifications, and alarms. Emergency physicians are interrupted, on average, nearly once every 5 minutes, and, perhaps more concerning, two thirds of those interruptions lead to a change in task.(2) Coeira and colleagues observed nurses and doctors in emergency departments and found that for both groups, about 80% of their time was taken up with communications activities.(3) During much of this time, the workers were also engaged in other tasks, and for an important fraction of it, they were involved in two or more simultaneous conversations.
Interruptions, distractions, and multitasking have long been associated with process failures. Almost half of National Transportation Safety Board (NTSB) investigations identify lapses of attention or divided attention (associated with interruptions or distractions) as contributors to the accident.(4)
But, while the high communications loads, interruptions, and distractions faced by health care workers are stressful and sometimes exceed the capacity of "merely extraordinary" human beings to keep up, at the same time, safety and productive performance in high-risk environments depend strongly on continuous communication and rapid updating of information.(5) Similarly, interruptions can be important if attention must be quickly redirected to urgent matters. Thus, a simplistic approach to reducing the volume of communications and interruptions may inadvertently make things worse instead of better. Even communications that are nominally unimportant (for example, because they are directed to someone other than the provider in question) may play a latent role in maintaining awareness of the ambient environment. Experts often monitor normal operations by listening to the background "chatter," not attending to any specific communication, but being alerted when the pattern of activity changes. Making communications and interruptions more useful and less distracting requires a careful balancing (4) of benefits and risks, informed by a deep, nuanced knowledge of the way technical work is performed at the "sharp end." It is ironic that the two factors that kept this case from becoming a tragedy were (i) an "error" (air in the IV line) and (ii) an interruption (the infusion pump alarming).
Health care workers often fail to consider the potential impact of their interruptions on others.(3,6) Moreover, current technological "solutions" to communications problems never show regard for others. Beepers, telephones, overhead pagers, and alarms never ask "Is this a good time?" or watch for a break in activity in which to insert themselves, balancing intrusiveness against importance as a thoughtful colleague might. Research on how to make technological aids more cooperative and less intrusive would be valuable before such devices are inserted into the complex environment of health care.
The nature of the task determines to a large and generally unappreciated extent the kinds of failures that may occur. Here, two task factors contributed to the nurse's failure to recognize that the wrong drug had been sent. First, she was traveling a seldom-traversed path in the web of activities associated with drug administration; calling the pharmacy to question drug correctness is (happily) not often required. Second, there was no natural cueing to the order of tasks; starting the infusion could easily be done with or without calling the pharmacy. When one step in a sequence does not depend on the prior successful completion of a previous step, or when the point at which to resume the task is not clearly represented in the work itself, steps are much more vulnerable to being omitted, or being performed out of order.(7) In such circumstances, it is quite easy to resume work after an interruption at a more "typical" spot—here, starting the infusion—since that is more familiar, is not precluded by omitting the call, and is suggested by the work environment (drug bottle sitting beside infusion pump but not connected).(8)
The Social Structure
Although much of the writing about emergency departments concerns biology, the most important things that happen there are social.(9) We do not know what the "getting yelled at" episode in this case was, but we do know that such behavior is common in the health care workplace and has negative effects on safety and performance. A 2003 survey of nurses and pharmacists reported that almost 90% had experienced intimidating behavior such as condescending language, and roughly half had experienced strong verbal abuse or threatening body language.(10) Such experiences alter caregivers' behaviors; almost three quarters of respondents reported deviating from normal procedures in order to avoid having to deal with a problematic provider. In addition, nurses routinely seek advice from those socially close to them, rather than from those best positioned to solve the problem.(11) The nurse in this situation did not feel that she could speak up; this reinforces authority gradients and inhibits the flow of potentially important information.(12) The aviation industry has institutionalized specific training to prevent this from happening.(13) The training focuses on flattening hierarchies and providing appropriate assertion tools for those lower in authority. For those higher in authority, the focus is on avoiding potentially intimidating behaviors and on actively eliciting information from others. Similar efforts have begun in some areas of health care (14), but have yet to be implemented in a comprehensive and sustained manner.
What Can Be Done?
Substantive improvements in the problems illustrated by this case will require a type of research that is new to health care, called "technical work studies."(15) Such studies will require collaborations between "safety scientists" (psychologists, engineers, human factors professionals, etc.) and health care providers. The research will need to focus on identifying the factors that make seemingly simple tasks (such as hanging an IV medication) hard; how vulnerabilities are detected; how workers negotiate these tasks (usually successfully, but occasionally not); and particularly, how new technology affects all the foregoing. Such baseline knowledge is a prerequisite for understanding whether a given intervention will work, in what contexts, and with what unintended consequences.
However, simply waiting for further research will be unsatisfactory for many. Although the available evidence is slim, some simple interventions have been suggested to begin addressing these issues. These include measures such as creating separate medication rooms with restricted entry to decrease interruptions during medication preparation; or identifying critical periods in briefly risky procedures where interruptions should be restricted to those of the highest urgency (for example, during emergency airway management).
- Interruptions are both beneficial and detrimental to safe performance. Only knowledge of the outcome determines when an interruption becomes a distraction.
- Consider identifying critical tasks during which interruptions should be minimized (eg, emergency airway management, medication preparation).
- Establish a code of conduct to reduce intimidating behaviors.
- Use caution when changing communications patterns, particularly when moving from rich (eg, face-to-face) to relatively impoverished (eg, tape-recorded) channels.
Robert L, Wears, MD, MS Professor of Emergency Medicine University of Florida, Jacksonville
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9. Vosk A, Milofsky C. The sociology of emergency medicine. Emergency Medicine News. February 2002;3ff.
10. Intimidation: practitioners speak up about this unresolved problem (part I). ISMP Medication Safety Alert! The Institute for Safe Medication Practices (ISMP) Web site. Available at: [ go to related site ]. Accessed August 11, 2004.
11. Tucker AL, Edmondson AC. Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003;45:55-72.
12. Morrison EW, Milliken FJ. Organizational silence: a barrier to change and development in a pluralistic world. Acad Manage Rev. 2000;25:706-25.
13. Helmreich RL, Merritt AC. Culture at work in aviation and medicine. Aldershot, UK: Ashgate Publishing; 1998.
14. Morey JC, Simon R, Jay GD, Rice MM. A transition from aviation crew resource management to hospital emergency departments: the Medteams story. In: Proceedings of the 12th International Symposium on Aviation Psychology. Columbus, OH: Ohio State University; 2003.
15. Barley SR, Orr JE, eds. Between craft and science: technical work studies in US settings. Ithaca, NY: Cornell University Press; 1997.